APPROACH TO HEMOLYTIC ANEMIA

Candidate: Dr SARATH MENON.R

K.B.ILLAVA HEMATOLOGY DIVISION

DEPT.MEDICINE,
MGM MEDICAL COLLEGE,INDORE
OBJECTIVES

 Lab indication of hemolysis

 Intravascular v/s extravascular hemolysis

 D/D of hemolytic anemia

 Diagnose hemo.anemia with peripheral smear &

ancillary lab tests
 HEMOLYTIC ANEMIA

 Definition:
 Those anemias which result from an increase in RBC
destruction coupled with increased erythropoiesis

 Classification:
 Congenital / Hereditary
 Acquired
CLASSIFICATION OF HEMOLYTIC ANEMIAS

INTRACORPUSCULAR EXTRACORPUSCULAR
DEFECTS FACTORS

HEREDITARY •HEMOGLOBINOPATHIES •FAMILIAL HEMOLYTIC

UREMIC SYNDROME
•ENZYMOPATHIES

•MEMBRANE-
CYTOSKELETAL DEFECTS

ACQUIRED •PAROXYSMAL •MECHANICAL DESTRUCTION

NOCTURNAL [MICROANGIOPATHIC]
HEMOGLOBINURIA •TOXIC AGENTS
•DRUGS
•INFECTIOUS
•AUTOIMMUNE
CLASSIFICATION
Intravascular hemolysis Extravascular hemolysis

 MAHA  Hemoglobinopathies
 Transfusion rx  Enzymopathies

 PNH  Membrane defects

 Infections  AIHA

 Snake bite
 HOW IS HEMOLYTIC ANEMIA DIAGNOSED?

Two main principles

 One is to confirm that it is hemolysis

 Two is to determine the etiology

HOW TO DIAGNOSE HEMOLYTIC ANEMIA
 New onset pallor or anemia

 Jaundice

 Splenomegaly

 Gall stones

 Dark colored urine

 Leg ulcers
 GENERAL FEATURES
OF HEMOLYTIC DISORDERS
 GENERAL EXAMINATION - JAUNDICE, PALLOR

BOSSING OF SKULL

 PHYSICAL FINDINGS - ENLARGED SPLEEN

 HEMOGLOBIN - FROM NORMAL TO SEVERELY REDUCED

 MCV - USUALLY INCREASED

 RETICULOCYTES - INCREASED

 BILIRUBIN - INCREASED[MOSTLY UNCONJUGATED]

 LDH - INCREASED

 HAPTOGLOBULIN - REDUCED TO ABSENT

HEMOLYTIC FACIES- CHIPMUNK FACIES
 Laboratory Evaluation of Hemolysis
Extravascular Intravascular
HEMATOLOGIC
Routine blood film Polychromatophilia Polychromatophilia
Reticulocyte count
Bone marrow Erythroid Erythroid
examination hyperplasia hyperplasia

PLASMA OR SERUM
Bilirubin Unconjugated Unconjugated
Haptoglobin , Absent Absent
Plasma hemoglobin N/
Lactate dehydrogenase (Variable) (Variable)

URINE
Bilirubin + +
Hemosiderin 0 +
Hemoglobin 0 + severe cases
POLYCHROMATOPHILIC CELLS
 THE KEY TO THE ETIOLOGY OF
HEMOLYTIC ANEMIA

 The history

 The peripheral blood film

 PATIENT HISTORY

 Acute or chronic

 Medication/Drug precipitants

G6PD

AIHA

 Family history

 Concomitant medical illnesses

 Clinical presentation
CASE 1
 3 yr old male child presenting with pallor,jaundice,
 Severe pain of long bones, fever

 CBC-anemia,reticulocytosis,increased WBC

 LAB - LDH -600 (normal upto 200)

S.bilirubin- 5mg%
PERIPHERAL SMEAR
WHAT IS THE DIAGNOSIS ?
 SICKLE CELL ANEMIA
DIAGNOSIS – OTHER TESTS

 Hemoglobin electrophoresis
-HbS >80%
-HbF -1-20%
-HbA2 -2- 4.5%

 Sickling test POSITIVE

 SICKLE CELL DISEASE
 Mutn .beta globin-6 Glu Val.
 Deoxy HbS (polymerised)

 Ca influx, K leakage

 stiff,viscous sickle cell

 venocclusion dec.RBC survival

microinfarctions,isch.pains anemia,jaundice,
autoinfarct.spleen gallstones,leg ulcers
CLINICAL MANIFESTATIONS
 Hemo.anemia,reticulocytosis,granulocytosis
 Vasoocclusion-protean

 Painful crises

 Splenic sequestration crises

 Hand foot syndrome

 Acute chest syndrome

DIAGNOSIS?
SICKLE THALASSEMIA`
 CLINICAL FEATURES OF SICKLE
HEMOGLOBINOPATHIES
Condition Clinical Hb level g% MCV,fl Hb
abnorm electropho
Sickle cell trait None,rare normal normal HbS/A:
painlss 40/60
hematuria
Sickle cell Vasocclusive 7-10 80-100 HbS/A:100/0
anemia crises,AVN,gal HbF;2-25%
lstones,
priapism

S/beta0 Vasoocclusive 7-10 60-80 HbS/A-100/0

thalasssemia Crises,AVN HbF; 1-10%

S/beta+ Rare crises, 10-14 70-80 HbS/A:

thalassemia AVN 60/40
HbSC --do--, 10-14 80-100 HbS/A;50/0
retinopathy HbC;50%
CASE 2
 6 yr old child presenting with severe pallor,jaundice
growth delay
 Abnormal facies,hepatosplenomegaly+

 h/o recurrent blood transfusions

 CBC-Hb -3gm%, MCV-58FL(Nl-86-98),

-MCH- 19pg (nl-28-33)

P.S- MICROCYTIC,HYPOCHROMIA with
target cells +
DIAGNOSIS?
TARGET CELLS
THALASSEMIA

 Other diagnosis test-Hb electrophoresis

 DNA analysis for mutations

 Alpha thalassemia & beta thalassemia

 Beta thalassemia- major

- intermedia
- minor
BETA THALASSEMIA
 Mutn. Beta globin expression

 M.C- derange splicing of m-RNA

 HYPOCHROMIA ,MICROCYTIC anemia

BETA THALASSEMIA MAJOR
 Severe homozygous
 Childhood, growth delay
 Severe anemia,hepatosplenomegaly,r/r transfusion
 Iron overload-endo.dysfnct

 P.Smear- severe microcytosis,target cells

Hb electro- HbF - 90-96 %

HbA2- 3.5 %- 5.5%
HbA - 0 %
BETA THALASSEMIA INTERMEDIA
 Similar stigmata like major
 Survive without c/c transfusion

 Less severe than major

 Moderate anemia,microcytosis,hypochromia

 Hb electrophor- HbF - 20-100%

HbA2 -3.5%-5.5%
HbA – 0-30%
BETA THALASSEMIA MINOR
 Profound microcytosis,target cells
 Minimal anemia

 Similar bld picture of iron def.anemia

 Lab inv:

MCV<75,Hct <30-33%
Hb electr: HbA2-3.5-7.5%,HbA-80-95%,HbF-1-5%
 ALPHA THALASSEMIAS
disease Hb A % HbH % Hb , % MCV,fl

normal 97 0 15 90

Thalassemia 90-95 rare 12-13 70-80

traits

HbH (b4) 70-95 5-30 6-10 60-70

Hb Bart 0 5-10 Fatal inutero or at

(hydrops birth
fetalis)
CASE 3
 45 yr old male came to opd in a remote PHC with
burning micturition
 Urine R/M shows numerous pus cells++++

 UTI diagnosed & medical officer gave

cotrimoxazole 2 bd X 5days
 1 wk later,pt developed severe
pallor,palpitation,jaundice
 Lab- increased LDH, S.BILIRUBIN,RETIC COUNT

 P.S- shows irreg cells like

BLISTER CELLS
HEINZ BODIES
DIAGNOSIS?
 G-6PD DEFICIENCY
 INVESTIGATION-

 Peripheral smear- bite cells,heinz bodies,

- polychromasia

G-6PD LEVEL

BEUTLER FLUORESCENT SPOT TEST-

Positive-if blood spot fails to flouresce in U V
 Clinical Features:
 Acute hemolysis:
Drugs,infections,asso with diabetic acidosis

 Favism

 Neonatal jaundice

 Congenital nonspherocytic hemolytic anemia

 Definitive risk Possible risk Doubtful risk

antimalarials Primaquine chloroquine quinine

Dapsone
cholrproguanil

Sulphonamides/ Sulphametoxazole Sulfasalazine Sulfisoxazole

sulphones Dapsone Sulfadimidine Sulfadiazine

Antibacterials/ Cotrimoxazole Ciprofloxacin Cholramphenicol

Antibiotics Nalidixic acid Norfloxacin p-Aminosalicylic
Nitrofurantoin acid

Antipyretic/ Acetanilide Acetylsalicylic acid Acetylsalicylic acid

Analgesics Phenazopyridine High dose[>3g/d] [<3g/d]
[pyridium] Acetaminophen
2. Pyruvate Kinase Deficiency
 AR
 Deficient ATP production, Chronic hemolytic
anemia
 Clinical features
o hydrops fetalis
o neonatal jaundice
o compensated hemolytic anemia
 Inv;
P. Smear: PRICKLE CELLS ( Contracted rbc with
spicules)

Decreased enzyme activity


PRICKLE CELL
CASE 4
 14 YR old female present with anemia, jaundice
 Rt hypochondrial pain

 o/e- vitals stable.pallor+,icterus+,splenomegaly +

 Usg- cholilithiasis

 Lab; elevated ,LDH, S.Bilirubin

 Peripheral smear shows-

DIFFERENTIAL DIAGNOSIS
 Hereditary spherocytosis

 Autoimmune hemolytic anemia

 Other diagnostic tests- osmotic fragility

- coombs test
RED CELL MEMBRANE DEFECTS

1.Hereditary Spherocytosis
 Usually inherited as AD disorder

 Defect: Deficiency of Beta Spectrin or Ankyrin  Loss of

membrane surface area becomes more spherical

Destruction in Spleen
 C/F:
Pallor
Jaundice

Splenomegaly

Pigmented gall stones- 50%

COMPLICATIONS

 Clinical course may be complicated with Crisis:

 Hemolytic Crisis: associated with infection

 Aplastic crisis: associated with Parvovirus infection

 Inv:

 Test will confirm Hemolysis

 P Smear: Spherocytes

 Osmotic Fragility: Increased

 Screen family members

AUTOIMMUNE HEMOLYTIC ANEMIA
 Result from RBC destruction due to RBC
autoantibodies: Ig G, M, E, A
 Most commonly-idiopathic

 Classification
 Warm AI hemolysis:Ab binds at 37degree Celsius
 Cold AI Hemolysis: Ab binds at 4 degree Celsius
1.Warm AI Hemolysis:
 Can occurs at all age groups
 F>M
 Causes:

50% Idiopathic
Rest - secondary causes:

1.Lymphoid neoplasm: CLL, Lymphoma,

Myeloma
2.Solid Tumors: Lung, Colon, Kidney, Ovary,
Thymoma
3.CTD: SLE,RA
4.Drugs: Alpha methyl DOPA, Penicillin ,
Quinine, Chloroquine
5. UC, HIV
 Inv:

 hemolysis, MCV decreased

 P Smear: microspherocytosis,

 Confirmation: Direct Coomb’s Test / Antiglobulin test

• 2. Cold AI Hemolysis
Usually Ig M directed at the RBC I antigen

 Infection: Mycoplasma pneumonia, Infec Mononucleosis

 Neoplasms : waldenstrom macroglobulinemia ,
lymphoma,CLL,kaposi sarcoma, myeloma.
 C/F:
Elderly patients

Exacerbations in the winter

Cold , painful & often blue fingers, toes,

ears, or nose ( Acrocyanosis)
 Inv:
 e/o hemolysis

 P Smear: Microspherocytosis

 DAT positive with polyspecific and anticompliment antisera

CASE 5
 32 yr old presented 4 days history of distention of
abdomen and rt hypochondrial pain and has h/o
passage of dark colored urine at night for weeks
 On USG- hepatomegaly,gross ascites,hepatic vein

thrombosis
Lab : Hb – 7gm%. WBC- 2200, PLC- 80,000
LDH- 600, S.BR- 4 mg%
urine bile pigment +,heme dip stick++

What is the diagnosis?

 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA
 Acquired chronic H.A
 Persistent intra vascular hemolysis

 Pancytopenia

 Lab :hburia,hemosiderinuria,increased LDH,bilirubin

 Risk of venous thrombosis

 C/F – hemoglobinuria during night

 P.S – polychromatophilia, normoblasts

 B.M – normoblastic hyperplasia

 Def.diagnosis-flow cytometry CD59-,CD55- RBC,WBC

- Hams’ acidified serum test

CASE 6
 25 yr old male with RHD – severe MR done MVR,after 10
days presented with pallor, palpitation,jaundice
CBC shows Hb – 7.5 gm %, Hct -22 %
Lab : S.bilirubin -4.5mg%
LDH -600
Retic count 10%

Peripheral smear –
MICROANGIOPATHIC HEMOLYTIC ANEMIA
NON-IMMUNE ACQUIRED HEMOLYTIC
ANEMIA
1. Mechanical Trauma
A). Mechanical heart valves, Arterial grafts: cause shear stress
damage
B).March hemoglobinuria: Red cell damage in capillaries of feet
C). Thermal injury: burns
D). Microangiopathic hemolytic anemia (MAHA): by passage of
RBC through fibrin strands deposited in small vessels 
disruption of RBC eg: DIC,PIH, Malignant HTN,TTP,HUS
MICROANGIOPATHIC HEMOLYTIC
ANEMIA(MAHA)

 Other findings - leukocytosis

- thrombocytopenia(DIC,TTP)
- hemoglobinuria
- deranged RFT
- PT,APTT prolonged
(DIC,TTP)
ACQUIRED HEMOLYSIS
Infection
F. malaria: intravascular hemolysis: severe called
‘Blackwater fever’
Cl. perfringens septicemia
Chemical/Drugs: oxidant denaturation of hemoglobin
Eg: Dapsone, sulphasalazine, Arsenic gas, Cu,
Nitrates & Nitrobenzene
 PERIPHERAL BLOOD SMEAR
 Spherocytes
AIHA, hereditary spherocytosis

 Schistocytes
With thrombocytopenia-Familial HUS TTP or DIC
Without thrombocytopenia- heart valve hemolysis

 Blister Cells
oxidative damage- G6PD
 Sickle cells
sickle cell anemia
 Heinz bodies
Alpha thalassemia
G6PD deficiency
CONCLUSION

 Hemolytic anemia can be recogised by clinical

picture-
- history & physical

- lab test to confirm hemolysis

- peripheral smear to guide further

tests
THANK YOU